Provider Demographics
NPI:1205996790
Name:EISNITZ, MARK F (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:F
Last Name:EISNITZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5265
Mailing Address - Country:US
Mailing Address - Phone:707-578-5566
Mailing Address - Fax:707-523-2855
Practice Address - Street 1:509 7TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5265
Practice Address - Country:US
Practice Address - Phone:707-578-5566
Practice Address - Fax:707-523-2855
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 4315103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL43150Medicare UPIN